International Journal of Contemporary Pediatrics

Chaitra KM et al. Int J Contemp Pediatr. 2018 Mar;5(2):462-466

http://www.ijpediatrics.com pISSN 2349-3283 | eISSN 2349-3291

DOI: http://dx.doi.org/10.18203/2349-3291.ijcp20180536
Original Research Article

Influence of nutritional status on clinical outcomes in

critically ill children
Chaitra K. M., Bhavya G.*, Harish S., Shruthi Patel, Syeda Kausar Anjum

Department of Paediatrics, KIMS, Bangalore, Karnataka, India

Received: 18 December 2017

Accepted: 20 January 2018

*Correspondence:
Dr. Bhavya G.,
E-mail: bhavyagg30@gmail.com

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Critically-ill children have a state of metabolic stress. The nutritional needs of these patients can be
increased. Their nutritional status at admission and its possible deterioration during hospitalization can be a predictor
of worse outcome. The objective of this study was to study the influence of nutritional status on outcomes like
mortality, duration of mechanical ventilation and duration PICU stay and hospital stay, in critically ill children.
Methods: This was a prospective comparative study conducted on 60 critically ill children aged 1 month to 18 years
admitted to PICU of tertiary care, teaching hospital, Bangalore, Karnataka over a study period of 12 months. Patients
were divided into 4 categories based on Body mass index (BMI) as per WHO growth charts into: underweight,
normal, overweight and obese and outcomes was analysed.
Results: In the present study 60 children were studied. Subjects were classified as underweight (23.33%), normal
weight (45%), overweight/obese (31.67%) based on BMI Z-score at admission. The odds of prolonged hospital stay
were higher in underweight and overweight/obese children (OR-2.85, p-0.12 and OR-3.92, p-0.03 respectively).
Underweight and overweight/ obese children had higher odds for prolonged PICU stay. (OR-6, p-0.02 and OR-2.13,
p-0.36 respectively). Underweight children required prolonged ventilator support (OR-2, p-0.03). There was no
significant difference among the group.
Conclusions: There is a high prevalence of malnourishment in critically ill children compared to general population
and they are prone for poor outcome. Malnourished children must be identified at admission and optimal therapies,
nutritional strategies aimed at preventing further nutritional deterioration should be made.

Keywords: BMI, Critically ill children, Malnourishment

INTRODUCTION ill patients would not survive. Critically-ill children have

Critical illness is a life-threatening multisystem process
requiring support of failing vital organ systems without
which survival would not be possible and also can result
in significant morbidity or mortality1. This condition can
be evoked by a variety of insults such as multiple trauma,
complicated surgery, and severe medical illnesses.
Paediatric intensive care unit (PICU) care aims at to
achieve timely diagnosis and therapeutic interventions for
controlling organ dysfunction and recover physiological
stability. Without modern critical care medicine, critically
a number of organic alterations, metabolic responses
which contribute to the maintenance of body
homeostasis, switching nutritional compounds towards
different functions and, at a further stage, may facilitate
recovery.
The metabolic response to stress can also include
catabolic processes that, in many circumstances, may
increase physiological instability and resource wasting.
Thus, causing an increase in nutritional requirements and
leading to state of metabolic stress.2

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 Chaitra KM et al. Int J Contemp Pediatr. 2018 Mar;5(2):462-466
Nutritional status can be assessed using clinical signs of
malnutrition, biochemical indicators, and anthropometry.
Anthropometry has an important advantage over other
nutritional indicators, it is non-invasive, inexpensive, and
relatively easy to obtain. Studies have documented that
nutritional status of critically ill children at admission and
its possible deterioration during hospitalization can be a
predictor of worse outcomes.3,4 But only a few studies
have examined the relationships between a range of
nutritional status categories i.e. underweight, normal
weight, overweight and obesity and clinical outcomes in
critically ill children.
This study was aimed to determine the influence
nutritional status at admission, as assessed by BMI Z-
score, on clinical outcomes in critically ill children. The
objective of this study was to study the influence of
nutritional status on outcomes like mortality, duration of
mechanical ventilation and duration PICU stay and
hospital stay, in critically ill children
METHODS
This was a prospective comparative study conducted on
60 critically ill children aged 1 month to 18 years
admitted to PICU of tertiary care, teaching hospital,
Bangalore, Karnataka over a study period of 12 months.
Ethics approval for the study was obtained from the
Institutional Review Board. All critically ill children
admitted to PICU in the age group of 1 month to 18 years
were included in the study excluding the children with
chromosomal anomalies, musculoskeletal disorders or
inborn error of metabolism
Detailed history and examination were done in all the
patients including the relevant investigation and the data
were collected at admission. Anthropometric parameters
including weight and height/length were taken by trained
personnel using the standardized technique within 24
hours of admission. Nutritional status on admission was
defined by BMI Z-score using the most recent World
Health Organization (WHO) growth charts. Subjects
Table 1: Characteristics of the study participants.
Underweight (n=14) Normal (n=27) Overweight or obese (n=19)
Median Age (IQR) 0.95 (0.25-3) 3.6 (1.3-5)
Age categories
Less than 1 year (n=10) 7 (50.0)
1-4 years (n=29) 4 (28.6)
5 years and above (n=21) 3 (21.4)
Gender
Male (n=39) 11 (78.6)
Female (n=21) 3 (21.4)
PRISM score 17.7 (7.1)
Duration of hospital stay 6.5 (5-7)
Duration of PICU stay 2.5 (1-4)
International Journal of Contemporary Pediatrics | March-April 2018 | Vol 5 | Issue 2
were categorized as 3 nutritional groups underweight
(BMI Z-score <-2), normal weight (BMI Z-score ≥-2 and
≤1), overweight (BMI Z-score >1 and ≤2) and obese
(BMI Z-score >2).5,6
Outcomes like mortality, duration of PICU stay, duration
of hospital stay, and duration of mechanical ventilation
were assessed in the groups.
Statistical Analysis
Statistical analysis was done using Stata student’s edition
version 12.
Continuous variables like PRISM score which followed
normal distribution have been summarized as mean and
standard deviation and compared between the nutrition
categories using one-way ANOVA test. Continuous
variables like age, duration of hospital stay and duration
of PICU say which did not follow normal distribution
have been summarized as median and inter quartile range
and compared between the nutrition categories using
Kruskal Wallis test. Overweight and obese children were
assessed together because of less number. Categorical
variables were summarized as proportions. Comparison
of proportions between the nutrition status categories was
done using fisher’s exact test. To assess association of
nutritional status with different morbidity and mortality
related outcomes, odds ratio with 95% confidence
interval was calculated. All statistical analysis was
considered significant if p value <0.05.
RESULTS
In the present study 60 children who met with inclusion
criteria were enrolled in to the study. Mean and median
age of the study population was 4.8 and 2.5 years
respectively with a standard deviation of 4.91. There
were 27 (45%) children who had normal BMI for age, 14
(23.33%) children were underweight and 19 (31.67%)
were overweight/ obese as per WHO charts.
P value
4.0 (1.7-10) 0.049
1 (3.7) 2 (10.5)
17 (63.0) 8 (42.1) 0.006
9 (33.3) 9 (47.4)
18 (66.7) 10 (52.6)
0.308
9 (33.3) 9 (47.4)
18.8 (11.5) 18.5 (8.3) 0.945
5.0 (3-7) 7.0 (4-8) 0.17
2 (1-3) 3 (2-3) 0.33
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 Chaitra KM et al. Int J Contemp Pediatr. 2018 Mar;5(2):462-466

Median age of the study population was comparable
among the groups but when age is categorised there was a
statistically significant (p-0.006) difference among the
group. Gender distribution and PRISM score was
comparable among the groups (Table 1). Duration of
hospital stay was compared among the Study groups, it
was seen that there was no statistically significant
difference among the groups (p value = 0.17) however
underweight and overweight/ obese children had higher
odds for prolonged hospital stay compared normal
children. (OR-2.85, p-0.12 and OR-3.92, p-0.03
respectively) (Table 2).

Table 2: Association between nutrition status and duration of hospital stay.

7-14 days <7 days

Odds ratio (95% CI) P value
N % N %
Normal 7 25.9 20 74.1 1 (Reference)
Underweight 7 50.0 7 50.0 2.85 (0.73-11.08) 0.12
Overweight or obese 11 57.9 8 42.1 3.92 (1.12-13.75) 0.03
Total 25 41.7 35 58.3

Table 3: Association between nutrition status and duration of PICU stay.

4 or more days <4 days

Odds ratio P value
N % N %
Normal 3 11.1 24 88.9 1 (Reference)
Underweight 6 42.9 8 57.1 6 (1.21-29.72) 0.02
Overweight or obese 4 21.1 15 78.9 2.13 (0.41-10.88) 0.36
Total 13 21.7 47 78.3

Table 4: Association between nutrition status and need for mechanical ventilation.

Required Not required

Odds ratio P value
N % N %
Normal 9 (33.3) 18 (66.7) 1 (Reference)
Underweight 7 (50.0) 7 (50.0) 2 (0.53-7.47) 0.03
Overweight or obese 6 (31.6) 13 (68.4) 0.92 (0.26-3.23) 0.9
Total 22 (36.7) 38 (63.3)

Table 5: Association between nutrition status and final outcome.

Death Recovered
Odds ratio P value
N % N %
Normal 9 (33.3) 18 (66.7) 1 (Reference)
Underweight 4 (28.6) 10 (71.4) 0.8 (0.19-3.27) 0.75
Overweight or obese 5 (26.3) 14 (73.7) 0.71 (0.19-2.61) 0.61
Total 18 (30.0) 42 (70.0)

Further when duration PICU stay was analysed among
the group, no statistically significant difference was
noted, however similar to Duration of hospital stay,
underweight and overweight/ obese children had higher
odds for prolonged hospital stay compared normal
children. (OR-6, p-0.02 and OR-2.13, p-0.36
respectively) (Table 3).
Further when ventilator days was analysed among the
group, underweight children required prolonged
ventilator support compared normal children and
overweight/ obese children. (OR-2, p-0.03) (Table 4).
Final outcome, mortality in children was compared a
shown in Table 5, and there was no significant difference
among the group.
DISCUSSION
PICU is an important component of tertiary paediatric
care service in care of critically ill children including
timely diagnosis and treatment. The main purpose of the
PICU is to prevent mortality and morbidity by intensively
monitoring and treating critically ill children who are
considered at high risk of mortality. The patient’s

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 Chaitra KM et al. Int J Contemp Pediatr. 2018 Mar;5(2):462-466
mortality not only depends on clinical characteristic of
patient, ICU performance, infrastructure but also on
nutritional status of the patient.7
A better understanding of the role of malnutrition in
critical illness and its effects on ultimate outcome of the
patient is of vital importance, in terms of the
interpretation of anthropometric data, and subsequent
prioritization of intervention and targeting strategies.
Assessment of malnutrition is often used to determine the
severity of morbidity and mortality.8
In our study, suboptimal nutritional status was
documented in nearly half (55%) of the critically ill
children on admission to the PICU. In that 23.33%
children were underweight and 31.67% were overweight/
obese as per WHO charts, which is more compared to
prevalence in general population signifying that
malnourished children are more liable for ICU care than
normal children.9,10
It was also seen that being underweight or
overweight/obese patients was associated with
significantly higher odds of prolonged PICU stay/hospital
stay compared to normal children which was in
accordance to Bechard et al, a two multicenter cohort
studies in Boston11, Nangula et al, a prospective study
conducted on a cohort of 400 children admitted to tertiary
care hospital, Ludhiana.12
Obesity/overweight was significantly associated
prolonged PICU care. The nature of the impact of obesity
on outcomes may depend on the individual patient and
illness type. Excess fat stores may affect ventilatory
status, potentially increasing dependence on respiratory
support. Patients who are obese may also be at greater
risk for complications.13
Underweight children had higher odds prolonged hospital
stay. Underweight could be a symptom of an underlying
disease or reason for admission that relates to mortality
risk. Underweight children may also have impaired
immune function that could limit their defence against
infections.14,15 Furthermore, critically ill children are at
risk of further nutritional deterioration during their illness
course due to disease or barriers to nutrient delivery in
the intensive care unit.11
Being underweight was associated with significantly
higher odds mechanical ventilation (OR-2, P value-0.03)
compared normal. This in accordance to de Souza MF et
al a prospective cohort study of children admitted to a
Brazilian PICU.16 In malnutrition, muscle function is
affected, originating muscle fatigue and a reduction of up
to 75% in work intensity and hence resulting in
respiratory failure.17-18
There was no statistically significant difference in
mortality among the 3 groups similar to a single center
retrospective study conducted by Goh et al on
mechanically ventilated children, overweight, obese or
International Journal of Contemporary Pediatrics | March-April 2018 | Vol 5 | Issue 2
severely obese children did not have any significant
difference in mortality, length of stay or duration of
mechanical ventilation, when compared to patients with
normal weight.19
Present results highlight the prevalence of malnutrition in
PICUs and the importance of anthropometry to allow
early interventions to be targeted in high-risk critically ill
children. Previous studies have used only weight for age
Z-scores to classify patients according to their nutritional
status. But weight alone as a marker of nutrition may be
misleading critical illness where fluid shifts are
commonly present.
Considering this weight for height or BMI provide a
better assessment of nutritional status in critical ill
children. This also has recommended as primary
indicators of nutritional status and growth in children.20
However lean body mass may be a more accurate
indicator.21
Other Anthropometric measurements such as mid-arm
circumference, triceps skinfold thickness, mid-arm
circumference can also be used to describe fat and
nutritional status.22 However, accurate measurements of
theses require expertise and experience. Despite its
limitations, BMI can be easily determined by weight and
height measurement and may be a better indicator than
body weight for evaluating the proportion of fat mass
relative to lean mass in children.23
Despite the prospective nature of our study, this study has
several limitations. Accurate measurement of weight and
particularly height may not be feasible in all critically ill
patients in addition alteration in the fluid balance during
acute phase of illness may lead to erroneous measurement
of weight and thereby BMI also.
CONCLUSION
Present study showed the high prevalence of
malnourishment in critically ill children compared to
general population. After stabilization of the initial
critical phase, PICU outcome is influenced by then
nutritional status of the children. Malnourished children
are more prone for prolonged hospitalisation and
ventilation. Malnourished children (both underweight and
obese) must be identified at admission by means of
simple anthropometric measures. And optimal Therapies
aimed at alleviating the underlying conditions and
nutritional strategies aimed at preventing further
nutritional deterioration should be made. Future studies
examining targeted strategies and their impact on
outcomes in malnourished children in the PICU are
desirable.
Funding: No funding sources
Conflict of interest: None declared
Ethical approval: The study was approved by the
Institutional Ethics Committee
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 Chaitra KM et al. Int J Contemp Pediatr. 2018 Mar;5(2):462-466
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Cite this article as: Chaitra KM, Bhavya G, Harish
S, Patel S, Anjum SK. Influence of nutritional status
on clinical outcomes in critically ill children. Int J
Contemp Pediatr 2018;5:462-6.
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